A nurse is caring for a patient immediately following endotracheal intubation.

Which of the following actions should the nurse prioritize to assess the patient for complications?

Auscultate lungs for the presence of breath sounds.

Determine that the pulse oximetry is greater than 95%.

Assess baseline level of consciousness.

Assess for the presence of circumoral cyanosis.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Auscultating the lungs for the presence of breath sounds is a priority action following endotracheal intubation. This helps to confirm correct tube placement and assess for complications such as a pneumothorax.
Choice B rationale
While it is important to ensure that the pulse oximetry is greater than 95% to confirm adequate oxygenation, this is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
Choice C rationale
Assessing the baseline level of consciousness is important, but it is not the priority action following endotracheal intubation.
Choice D rationale
Assessing for the presence of circumoral cyanosis can indicate hypoxia, but it is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.

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Correct Answer is ["A","D","E"]

Explanation

Choice A rationale
Culturally incompetent caregivers can be a significant barrier to appropriate communication with clients. Cultural competence involves understanding and respecting the cultural differences and preferences of clients, which can greatly influence how they perceive and respond to healthcare communication.
Choice B rationale
Proper training in healthcare communication is not a barrier, but rather a facilitator of appropriate communication with clients. It equips healthcare professionals with the necessary skills and knowledge to communicate effectively with clients.
Choice C rationale
Excellent health literacy is not a barrier, but rather a facilitator of appropriate communication with clients. Clients with excellent health literacy are better able to understand and engage in healthcare communication.
Choice D rationale
Implicit bias can be a significant barrier to appropriate communication with clients. It refers to the unconscious attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.
Choice E rationale
Lack of diversity can be a significant barrier to appropriate communication with clients. Diversity in the healthcare workforce can enhance the understanding of the cultural and social needs of diverse client populations, thereby improving communication.

A. “Don’t be too hard on yourself. It’s uncertain if your smoking led to the cancer.”. B. “It’s normal to feel scared. What aspects of cancer frighten you the most?” C. “Do you feel guilty because you used to smoke?” D. “Fear is a normal reaction. We are here to support you through this.”. .

Correct Answer is B

Explanation

Choice A rationale
While it’s important to reassure the patient, saying “It’s uncertain if your smoking led to the cancer” might be misleading. Smoking is a major risk factor for lung cancer, but it’s also true that not everyone who smokes gets lung cancer, and not everyone who gets lung cancer has smoked.
Choice B rationale
This response validates the patient’s feelings and opens up a dialogue about their specific fears. It allows the nurse to provide targeted education and reassurance.
Choice C rationale
Asking “Do you feel guilty because you used to smoke?” might make the patient feel more guilty or judged. It’s better to provide support and understanding.
Choice D rationale
While it’s true that fear is a normal reaction and that the healthcare team is there to support the patient, this response doesn’t address the patient’s specific concerns or feelings of guilt.

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A nurse is caring for a patient immediately following endotracheal intubation. Which of the following actions should the nurse prioritize to assess the patient for complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A new graduate nurse attends a seminar on Communication in Healthcare. Which of the following are considered barriers to appropriate communication with clients? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

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Correct Answer is B

Explanation

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A nurse is caring for a patient immediately following endotracheal intubation.

Which of the following actions should the nurse prioritize to assess the patient for complications?